Feasibility and outcomes of emergency laparoscopic TAPP repair for strangulated inguinal hernia

Abstract

Background

The use of laparoscopy for strangulated inguinal hernia remains controversial, especially when bowel ischemia is suspected. This study evaluated the feasibility and outcomes of emergency laparoscopic TAPP repair in patients with strangulated inguinal hernia and examined preoperative factors associated with bowel resection.

Methods

We reviewed all patients who were first treated laparoscopically for a strangulated inguinal hernia from April 2024 to December 2025. If laparoscopic reduction failed and conversion was needed, those cases were described separately. The same TAPP technique was used for all, with either a 12 × 15 cm or 15 × 15 cm polypropylene mesh fixed with nonabsorbable tacks. We used univariable analysis to look at factors linked to bowel resection, and described recurrence during follow-up.

Results

Of the 62 patients initially approached laparoscopically, 11 (17.7%) required conversion to open repair because reduction was not possible. Two of these 11 needed bowel resection due to bowel ischemia. The main group for analysis included 51 patients who had a completed TAPP repair. Bowel resection was needed in 5 of these patients (9.8%; 95% CI 3.3–21.4%). Longer symptom duration and higher CRP levels were strongly linked to needing bowel resection. During a median follow-up of 16 months (IQR, 10.5–20 months), 6 patients (11.8%; 95% CI 4.4–23.9%) had recurrence. There were no deaths.

Conclusion

Emergency laparoscopic TAPP repair appears feasible and safe in well-chosen patients with strangulated inguinal hernia, as long as laparoscopic reduction is possible. Longer symptoms and higher CRP levels were linked to a greater need for bowel resection, but these findings should be viewed with caution because of the small number of cases. These findings support a laparoscopic-first approach in appropriately selected patients, but more research from larger, multicenter studies is needed to confirm these findings and improve patient selection.

Introduction

Strangulated inguinal hernia is a surgical emergency that can cause serious illness or death, especially if the bowel loses blood supply, becomes necrotic, or perforates. If treatment is delayed, the bowel may be damaged and need to be removed, which raises the risk of complications after surgery. Quick surgery is essential to prevent these problems [1]. While ‘incarcerated’ and ‘strangulated’ hernia are sometimes used as synonyms, this study focused on patients with suspected strangulated hernia, defined as an irreducible groin hernia with signs of bowel ischemia, such as ongoing pain or signs of bowel blockage.

Open surgery has long been the standard treatment for strangulated inguinal hernia. Surgeons have been cautious about using laparoscopy in emergencies, especially when the bowel may be severely damaged, because it can be hard to assess bowel viability, avoid contamination, and safely use mesh [2].

As minimally invasive surgery and laparoscopic skills have improved, the traditional preference for open surgery is being reconsidered. Laparoscopic TAPP repair can offer better views of the trapped bowel, allow inspection of the whole abdomen, and help assess bowel viability. It is also linked to less pain after surgery, shorter hospital stays, and quicker recovery compared to open surgery, both in planned and some emergency cases [3].

Despite these possible benefits, using laparoscopic TAPP repair for strangulated inguinal hernia is still debated. There is not much strong evidence, and current studies often have small groups of patients and different criteria. Reliable data on how often laparoscopic reduction works, the safety of mesh use, complications, recurrence, and the need for bowel resection in emergency TAPP cases are still limited [4].

It is important to identify which patients are more likely to need bowel resection. Good preoperative predictors can help plan surgery, guide discussions with patients, and choose the best surgical method [5]. Markers like CRP and NLR, as well as how long symptoms last, have been suggested as signs of severe bowel ischemia. However, their usefulness in emergency laparoscopic hernia repair is still unclear [6].

Hernia recurrence after emergency repair is still a major concern. The reasons for recurrence are not fully understood, and it is unclear how much surgical technique, bowel damage, or features like hernia size contribute. Some recent studies suggest that how the defect is managed and the choice of mesh can affect recurrence after laparoscopic repair [7]. Still, there is little data on recurrence after emergency laparoscopic procedures [8].

This study aimed to evaluate the feasibility and outcomes of emergency laparoscopic TAPP repair in patients with strangulated inguinal hernia, to report conversion outcomes, and to examine preoperative factors associated with bowel resection.

Materials and methods

Study design and patient selection

This retrospective, single-center study included all consecutive patients who were initially approached laparoscopically for a suspected strangulated inguinal hernia between April 2024 and December 2025.

Strangulated inguinal hernia was defined as an irreducible groin hernia associated with persistent pain and clinical findings suggestive of compromised bowel perfusion, including signs of intestinal obstruction. Preoperative imaging findings, when available, were reviewed and considered supportive but were not mandatory for diagnosis. Bowel viability was ultimately assessed intraoperatively.

Patients were considered candidates for an initial laparoscopic approach if they were hemodynamically stable and had no evidence of generalized peritonitis, bowel perforation, or severe intra-abdominal contamination. The decision to attempt laparoscopic repair was made by the attending surgeon based on clinical and radiological findings. All procedures were performed by surgeons experienced in advanced laparoscopic hernia surgery.

During the study period, 62 patients were approached laparoscopically initially. Conversion to open repair was performed when safe laparoscopic reduction could not be achieved. No intraoperative bowel perforations occurred. Eleven patients (17.7%) required conversion because of failure of laparoscopic reduction; two of these required bowel resection because of bowel ischemia. Converted cases were analyzed descriptively and reported separately but were excluded from the primary outcome analysis because the study focused on outcomes after successfully completed TAPP repair, whereas recurrence- and mesh-related outcomes cannot be meaningfully attributed to TAPP in converted cases.

Accordingly, the primary study population consisted of 51 patients in whom laparoscopic TAPP repair was successfully completed.

Surgical technique

All completed procedures were performed using a standardized TAPP approach. Following induction of general anesthesia, pneumoperitoneum was established, and the hernia contents were carefully reduced. After assessment of bowel viability, a 12 × 15 cm or 15 × 15 cm heavyweight polypropylene mesh (PAHA^®, Türkiye) was placed in the preperitoneal space to ensure adequate coverage of the myopectineal orifice. Mesh fixation was performed using nonabsorbable tackers in accordance with standard TAPP principles. The peritoneal flap was subsequently closed to completely separate the mesh from the abdominal cavity.

After reduction of the incarcerated bowel, bowel viability was assessed laparoscopically according to bowel colour, restoration of peristalsis, mesenteric arterial pulsation, and bowel wall perfusion. When bowel viability remained uncertain, the bowel was observed laparoscopically for a short period following warm saline irrigation to allow reassessment of colour and peristaltic activity. Bowel resection was performed only when irreversible ischemia or transmural necrosis was considered present by the operating surgeon. When bowel resection was required, it was performed laparoscopically.

Data collection

Patient data were obtained from institutional electronic medical records. Demographic variables included age and sex. Clinical parameters included symptom duration prior to hospital admission and length of hospital stay. Preoperative laboratory variables included white blood cell count, CRP, and serum albumin levels. CRP values were reported in mg/L.

Inflammatory indices, including the NLR and platelet-to-lymphocyte ratio (PLR), were calculated from absolute blood counts. Operative variables included intraoperative findings, the need for bowel resection, and the hernia defect size, measured intraoperatively at its maximal transverse diameter.

Postoperative outcomes included complications, recurrence, and mortality. Complications were graded according to the Clavien–Dindo classification system. Recurrence was confirmed by clinical examination and/or imaging when indicated.

Patients were routinely evaluated approximately one month after surgery. Follow-up visits were recommended at 12 and 24 months after surgery. Patients who did not attend their scheduled follow-up visits were contacted by telephone and invited to return for clinical evaluation. Patients who developed symptoms suggestive of recurrence before the scheduled follow-up visits were evaluated earlier. Hernia recurrence was assessed by clinical examination and confirmed by imaging when necessary. Additional follow-up visits were arranged according to clinical need. The median follow-up duration was 16 months (IQR, 10.5–20 months). Clinical follow-up was completed in 36 of 51 patients (70.6%) at 12 months. Fifteen patients (29.4%) did not complete the scheduled 12-month clinical assessment. At 24 months, clinical follow-up was completed in 2 of 51 patients (3.9%), whereas the remaining patients had not yet reached or completed the planned 24-month follow-up.

Outcomes

The primary outcome was the requirement for bowel resection during emergency laparoscopic TAPP repair. Secondary outcomes included postoperative complications, hernia recurrence, conversion to open surgery, length of hospital stay, and mortality.

Statistical analysis

Statistical analyses were performed using IBM SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA). Continuous variables were assessed for normality using the Shapiro–Wilk test and are presented as mean ± standard deviation or median with interquartile range (IQR), as appropriate. Comparisons between patients with and without bowel resection were performed using univariable analyses. Continuous variables were compared using the Mann–Whitney U test or Student’s t-test, as appropriate, and categorical variables were compared using Fisher’s exact test.

Confidence intervals for proportions were calculated using the Clopper–Pearson method. Because of the limited number of bowel resection and recurrence events, multivariable regression analyses and predictive modeling were not performed to avoid overfitting and unreliable estimates. A two-sided p-value below 0.05 was considered significant. Nevertheless, appropriate univariable inferential statistical analyses were retained because they provide statistically valid exploratory comparisons while avoiding the risk of overfitting associated with multivariable modeling in very small datasets.

Results

Overall cohort and conversion outcomes

During the study period, 62 patients were initially approached laparoscopically for suspected strangulated inguinal hernia.

Eleven patients (17.7%) required conversion to open repair because safe laparoscopic reduction could not be achieved. No intraoperative perforations occurred. Bowel resection was required in 2 of the converted patients (18.2%) because of bowel ischemia. No mortality occurred in the conversion group (Table 1).

Table 1.

Comparison of patients with completed laparoscopic TAPP repair and those requiring conversion

Variable	Completed TAPP (n = 51)	Converted to Open Repair (n = 11)
Bowel resection	5 (9.8%)	2 (18.2%)
Mortality	0	0
Reason for conversion	—	Failure of laparoscopic reduction
Intraoperative perforation	0	0

Converted cases were excluded from the primary outcome analysis, which focused on patients in whom laparoscopic TAPP repair was successfully completed

Accordingly, the primary analysis cohort consisted of 51 patients who underwent completed laparoscopic TAPP repair.

Patient characteristics

Baseline demographic, clinical, and laboratory characteristics of the completed TAPP cohort are summarized in Table 2. The mean age was 60.3 ± 16.5 years, and the majority of patients were male (44/51). The median symptom duration prior to admission was 4 h (IQR 2.5–6.0). Preoperative laboratory evaluation demonstrated a median CRP level of 0.7 mg/L (IQR 0.3–2.95) and a median NLR of 5.24 (IQR 2.50–8.89).

Table 2.

Baseline characteristics of patients with completed laparoscopic TAPP repair (n = 51)

Variable	Value
Number of patients	51
Age, years (mean ± SD)	60.3 ± 16.5
Sex, male/female	44 / 7
Symptom duration, hours (median, IQR)	4 (2.5–6.0)
White blood cell count (×10⁹/L), mean ± SD	11.2 ± 4.3
CRP, mg/L (median, IQR)	0.7 (0.3–2.95)
Albumin, g/dL (mean ± SD)	4.10 ± 0.49
NLR (median, IQR)	5.24 (2.50–8.89)
PLR (median, IQR)	171.8 (100.3–204.1)

IQR interquartile range, CRP C-reactive protein, NLR neutrophil-to-lymphocyte ratio, PLR platelet-to-lymphocyte ratio

Operative outcomes

Bowel resection was required in 5 patients (9.8%; 95% CI 3.3–21.4%). All resections were completed laparoscopically.

Three patients (5.9%) had minor complications after surgery, such as mild bleeding or hematoma, which were managed without transfusion, further procedures, or reoperation (Clavien–Dindo grade I). There were no major complications, mesh infections, or deaths.

The median hospital stay was 1 day (IQR 1–1). Patients who needed bowel resection, however, stayed in the hospital much longer than those who did not (Table 3).

Table 3.

Comparison of patients with and without bowel resection in the completed TAPP cohort

Variable	No resection (n = 46)	Resection (n = 5)	p-value
Age, years (median, IQR)	58 (52–70)	68 (57–74)	0.61
Symptom duration, hours (median, IQR)	4 (2–5)	20 (18–22)	< 0.01
Length of hospital stay, days (median, IQR)	1 (1–1)	5 (4–6)	< 0.001
CRP, mg/L (median, IQR)	0.5 (0.3–1.97)	19.8 (12.89–25.31)	< 0.01
Albumin, g/dL (mean ± SD)	4.15 ± 0.44	3.58 ± 0.66	0.06
NLR (median, IQR)	5.11 (2.46–7.24)	9.01 (7.68–13.60)	0.07
PLR (median, IQR)	163.5 (89.0–193.5)	207.0 (201.1–243.4)	0.06

IQR interquartile range, CRP C-reactive protein, NLR neutrophil-to-lymphocyte ratio, PLR platelet-to-lymphocyte ratio

The median follow-up duration was 16 months (IQR, 10.5–20 months). Clinical follow-up was completed in 36 of 51 patients (70.6%) at 12 months and in 2 of 51 patients (3.9%) at 24 months. During follow-up of up to 24 months, hernia recurrence occurred in 6 patients (11.8%; 95% CI 4.4–23.9%).

Predictors of bowel resection

Comparisons between patients requiring bowel resection and those who did not are presented in Table 3. Patients undergoing bowel resection had significantly longer symptom duration (median 20 vs. 4 h; p < 0.001) and higher CRP levels (median 19.8 vs. 0.5 mg/L; p < 0.001). They also experienced significantly longer hospital stays. Lower serum albumin levels and higher NLR values demonstrated trends toward association with bowel resection but did not reach statistical significance. Age, white blood cell count, and PLR were not significantly associated with the need for bowel resection.

NLR and serum albumin levels showed a trend toward significance but did not reach significance in univariable analysis (p = 0.0729 and p = 0.0609, respectively). Age, white blood cell count, and PLR were not significantly linked to needing bowel resection.

Because only six recurrences occurred during follow-up, no further statistical analysis of recurrence was performed.

Discussion

There is still debate about using laparoscopy for emergency treatment of strangulated inguinal hernia because of worries about bowel damage, contamination, and recurrence. Open surgery has usually been preferred, especially when bowel ischemia is suspected [9]. But as surgeons gain more experience with laparoscopy, recent studies show that minimally invasive repair can be safe and practical for selected emergency cases [10].

In this study, 62 patients started with a laparoscopic approach, but 17.7% needed to switch to open surgery because reduction was not possible. This shows that laparoscopy is not suitable for all strangulated hernias and highlights the importance of careful patient selection and sound clinical judgment during emergency surgery. Still, for those who had successful TAPP repair, complications were few, there were no deaths, and bowel resection could be done laparoscopically if needed. These findings support a laparoscopic-first approach in appropriately selected patients.

Bowel resection was needed in 9.8% of completed cases, which matches earlier reports on emergency groin hernia repair [11]. All resections were done laparoscopically, and there were no mesh infections. While using mesh when there is bowel ischemia or after bowel resection is still debated, recent studies suggest it can be safe in selected patients if there is no major contamination or perforation [12]. Our findings support this idea and the careful use of mesh in emergency laparoscopic repairs.

Longer symptom duration and higher CRP levels were strongly linked to needing bowel resection in our analysis [13]. This makes sense, as longer incarceration can cause more tissue damage, and high CRP shows a stronger inflammatory response. Other studies on abdominal wall hernias have found similar results [11]. However, because there were few cases of bowel resection, these findings should be viewed with caution and need to be confirmed in larger studies.

Hernia recurrence was observed in 11.8% of patients during follow-up. Although this rate appears higher than that reported in most elective TAPP series, direct comparison should be interpreted cautiously because the present study included only emergency repairs for strangulated inguinal hernia. Emergency procedures are technically more demanding owing to bowel edema, tissue inflammation, distorted anatomy, and the urgent operative setting, all of which may adversely affect optimal mesh positioning and fixation [14, 15]. Importantly, no recurrence occurred among patients who underwent bowel resection, and no mesh infections were observed, suggesting that contamination associated with bowel resection was unlikely to explain the observed recurrence rate. Because only six recurrence events occurred, no reliable subgroup analysis could be performed to identify independent factors associated with recurrence. Therefore, the observed recurrence rate should be interpreted cautiously because of the limited sample size and incomplete long-term follow-up, and should be regarded as exploratory.

Overall, there were few complications after surgery, and these were minor bleeding problems managed without further intervention. There were no major complications, mesh infections, or deaths. Patients who needed conversion had more bowel resections but no deaths, suggesting that not being able to reduce the hernia laparoscopically may mean the disease was more advanced, not that the surgery itself was riskier. Taken together, these results support using laparoscopy for strangulated inguinal hernia in stable patients without perforation or major contamination [16].

Limitations

This study has several limitations. First, its retrospective single-center design may have introduced selection bias. Although all patients initially managed laparoscopically were included, those requiring conversion to open surgery were excluded from the primary analysis because recurrence- and mesh-related outcomes cannot reasonably be attributed to laparoscopic TAPP when the intended procedure could not be completed. Therefore, the findings primarily reflect outcomes after successfully completed laparoscopic TAPP repair. Given the relatively small sample size and limited number of outcome events, the present findings should be regarded as exploratory and hypothesis-generating. Larger prospective multicenter studies are required before firm conclusions can be drawn.

Second, the small number of bowel resection and recurrence events limited the statistical power of the study and precluded multivariable analyses, making the findings exploratory rather than confirmatory.

Third, although all procedures were performed using a standardized surgical technique, some potentially relevant anatomical variables, such as detailed hernia morphology and defect characteristics, as well as surgeon-specific factors, were not systematically recorded.

Finally, despite an active follow-up protocol, follow-up duration varied among patients, which may have influenced the assessment of long-term recurrence and other late outcomes. Therefore, the estimated recurrence rate should be interpreted cautiously because of the relatively small sample size and incomplete long-term follow-up.

Future prospective multicenter studies with standardized follow-up protocols and larger patient populations are warranted to validate these findings.

Accordingly, the present analyses should be interpreted as exploratory and hypothesis-generating rather than confirmatory.

Conclusion

Emergency laparoscopic TAPP repair appears feasible in selected patients with strangulated inguinal hernia if laparoscopic reduction is possible. Bowel resection was also possible using laparoscopy, with no mesh infections or deaths. Longer symptoms and higher CRP were linked to needing bowel resection, but these results should be viewed with caution because of the small number of cases. More prospective studies are needed to confirm these findings.

Authors’ contributions

OGG conceptualized and designed the study. OGG and SAK contributed to data collection. OGG performed the statistical analysis and drafted the initial manuscript. SAK critically revised the manuscript for important intellectual content. Both authors interpreted the data, approved the final version of the manuscript, and agree to be accountable for all aspects of the work.

Funding

The authors received no specific funding for this research. No financial support, grants, or institutional funding was used during the study period.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the ethical standards of the Declaration of Helsinki. Ethical approval was obtained from the Clinical Research Ethics Committee of Malatya Turgut Özal University (Approval No: E-30785963-020-370844). Owing to the retrospective design of the study and the use of anonymized data, the Clinical Research Ethics Committee of Malatya Turgut Özal University waived the requirement for informed consent for study participation. All patients had provided routine procedural consent for emergency surgery, including laparoscopic exploration and possible conversion to open repair when clinically indicated.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.